Introduction to Physical Exams

O: Objective

signs that can be seen or measured.

visual acuity charts

snellen chart used to test far vision, Jaeger chart used to test near vision, and Ishihara plates used to test color vision

percussion

tapping on a surface to determine the difference in the density of the underlying structure

Which of the following would be most appropriate for an examination of the rectum?

Sim's

In relation to medical records, what does the acronym SOAP stand for?

Subjective, Objective, Assessment, Plan

prenatal exam

given to a woman during pregnancy

Subjective examples:

headache, back pain, nausea, and fatigue

otoscope

instrument for examining the ear

sphygmomanometer

instrument to measure blood pressure

stethoscope

instrument used for listening to internal body sounds

tonometer

instrument used to measure eye pressure

manipulation

moving a joint to determine range of motion and flexion

A: Assessment

physical evaluation of signs and symptoms

documentation

- MA do most documentation of a physical exam appointment in the pt's medical record

knee chest position

- examine the anus and rectum - MA should provide support as needed - should not be placed in this position till Dr arrives

prone position

- examine the back, feet, or spine

dorsal recumbent position

- examine the head, chest, or abdomen - used on pt's older, arthritis, or back pain - used for vaginal/rectal exams, or insertion of urinary catheters

fowlers position

- examine the head, neck,and upper body - commonly used for pts with respiratory difficulties

Why is appropriate draping so important during physical exams?

Draping helps to preserve a patient's dignity.

EENT exam

Eye, ear, nose and throat examination

In which direction does the patient lay while in the supine position?

Face-up

A drape is not needed if a patient is being examined in the sitting position.

False

Why is it important for the medical assistant to remain in the room with the physician and patient during a physical exam?

For legal protection

Which instrument is used to measure range of motion?

Goniometer

What is a tuning fork?

Instrument used to test hearing

Which two tools would be most helpful when examining the throat?

Laryngeal mirror and tongue depressor

auscultation

Listening with a stethoscope

What is the name of the position in which a patient lays face-up with the feet elevated in stirrups?

Lithotomy

Why is the knee-chest position considered risky?

Patients may easily lose their balance in this position.

Why might microscope slides be needed for a gynecological exam?

To collect cells for a Pap test

tuning fork

Used to test hearing

Which of the following is used to open the vagina during a gynecological exam?

Vaginal speculum

CPE

complete physical exam

prenatal exam purpose

examination of the mother and the fetus

S: Subjective

finding symptoms. Are complains made by the pt that can not be seen or measured by another person

GYN exam

gynecological exam

Plan Examples:

may order a throat culture, prescribe penicillin, and request to see the pt for a follow-up appointment in 5 days

tape measure

measure the circumference of body parts, such as the head

SOAP notes

notes to record progress notes from an exam

inspection

observing a pt's general condition, including speech, skin condition, color posture, gait, awareness, sensitivity, anxiety, and grooming

Assessment examples:

pt complains of a sore throat and fever, and the throat shows signs of swelling and infection, the physician may suspect strep throat.

Objective examples:

rashes, bleeding, and swelling. Vital signs and body measurements

CPE purpose

review of the entire body and all body system

well-child visit

routine examination of a pediatric pt

EENT exam purpose

screenings for vision and hearing problems

P: Plan

the poposed course of action.

mensuration

the process of measuring a patient

cervical brush, spatula, and ayer blade

used to collect cells from the vaginal walls and cervix

What piece of equipment is needed for the proctologic position?

Proctologic exam table

sitting position

- first and last position during an exam - used to obtain pt's vital signs and gather medical history. - examine pt's head and neck, listening for heart and lung sounds - testing reflexes

equipment

- MA must prepare an exam room, and anticipate the equipment that the Dr will need

proctologic position

- examine of the anus and rectum - created to eliminate the need for the uncomfortable and potentially dangerous knee chest position.

sims position

- examine the rectum/vagina - used to administer enemas/taking a rectal temp

CPE known also

- general physical exam - physical exam - history and physical - physical

Role of MA:

- help physician and pt - prepare exam room - gather equipment, and make sure they work - prepare pt - gather pt specimens and complete UA and Blood tests - handing equipment to Dr - record findings dictated by the Dr - help pt down from exam table - answer any further questions - clean up room - complete any remaining medical record papers

draping purposes:

- preserve a pt's dignity - keep pt warm and comfortable

supine position

- recumbent position - examine the front of the body, including head, chest, abdomen, arms and legs

Tredelenburg position

- used for pelvic exam or surgery - used to increase blood circulation to the heart and brain

lithotomy position

- used for rectal and pelvic examinations

nasal speculum

An instrument used to examine the inside of the nose

Which of the following is a role of a medical assistant during a physical exam?

Assist the physician as needed

Which examination technique involves listening to internal body sounds with a stethoscope?

Auscultation

Which of the following is an examination of the entire body and all body systems?

CPE

What is the name of the position in which a patient lays face-up with knees bent and feet flat on the table?

Dorsal recumbent

Which of the following is most likely to occur while a patient is in the sitting position?

Evaluating the patient's reflexes

In which position is the head of the bed elevated?

Fowler's

ophthalmoscope

Instrument used to examine the eyes

Why should the physician be consulted before placing an elderly patient into the prone position?

Limited range of motion in their necks can make it uncomfortable.

When Gina brings her 3-month-old daughter to the pediatrician for a well-baby check-up, the medical assistant measures the baby's height, weight, and head circumference. What type of examination technique is this?

Mensuration

Which of the following is a lighted tool used to examine the ears?

Otoscope

Which examination technique involves touching the patient with fingers or hands?

Palpation

What technique is Dr. Crosby using when she taps a patient's flesh and listens for sounds from the underlying organs?

Percussion

Which of the following is an example of a subjective finding?

The patient complains of dizziness and nausea.

Which of the following is an example of an objective finding?

The patient has a fever of 102° F.

What is the purpose of a percussion hammer?

To test reflexes

Which tool would be most helpful when testing vision?

Visual acuity chart

lubricant

a fluid used to reduce friction

physical exam

an examination by the physician of all or part of a pt's body

GYN exam purpose

an examination of the female reproductive organs

Goniometer

an instrument for measuring angles

laryngeal mirror

an instrument used to examine the throat and larynx

vaginal speculum

an instrument used to open the vagina to examine it and the cervix

The Trendelenburg position increases circulation to the ____.

brain and heart

specimen cup

contains specimen samples

tongue blade/depressor

flat stick to old down tongue when examining the throat

palpation

to examine by touch. Determining temp, size, and shape of organs, and the presence of abnormal structures

percussion hammer

used to test reflexes.